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Year : 2017  |  Volume : 61  |  Issue : 5  |  Page : 63-65  

Assessment of urinary cotinine levels in women with gynecological complaints at a tertiary care hospital: A pilot study

1 Senior Specialist, Department of Obstetrics and Gynaecology, Guru Teg Bahadur Hospital, New Delhi, India
2 Assistant Professor, Department of Obstetrics and Gynaecology, Guru Teg Bahadur Hospital, University College of Medical Sciences, New Delhi, India
3 Regional Advisor, Tobacco-Free Initiative, Regional Office for South-East Asia, World Health Organization, New Delhi, India
4 PhD student Biochemistry, Department of Biochemistry, Delhi University, New Delhi, India
5 Professor, Department of Biochemistry, University College of Medical Sciences, New Delhi, India

Date of Web Publication15-Sep-2017

Correspondence Address:
A G Radhika
Department of Obstetrics and Gynaecology, Guru Teg Bahadur Hospital, Dilshad Garden, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_266_17

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Gynecological effects due to smokeless tobacco exposure are not well studied. This cross-sectional study was undertaken with the objective to evaluate the urinary cotinine levels in women of reproductive age with gynecological complaints. The study was conducted in 2015 at the outpatient clinic of the Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi. A total of 192 consecutive women presenting with gynecological complaints (pelvic inflammatory disease (PID), infertility, and menstrual abnormality) were recruited. Their demographic details and tobacco exposure were recorded. All of them denied exposure to any form of tobacco. Urinary cotinine level of each participant was measured. The mean urinary cotinine level was 23.60 ± 12.00 ng/ml. PID was the most common gynecological complaint. Women with PID had significantly higher urinary cotinine levels compared to those with menstrual complaints and infertility: 24.9548 (±12.259) ng/ml versus 20.2042 (±10.9248) ng/ml. This study highlights the importance of addressing the issue of secondhand smoke exposure and reproductive morbidities in women.

Keywords: Abnormal uterine bleeding, infertility, pelvic inflammatory disease, secondhand smoke, smokeless tobacco, urinary cotinine, women

How to cite this article:
Radhika A G, Bhaskaran S, Kaur J, Singla A, Sharma T, Banerjee B D. Assessment of urinary cotinine levels in women with gynecological complaints at a tertiary care hospital: A pilot study. Indian J Public Health 2017;61, Suppl S1:63-5

How to cite this URL:
Radhika A G, Bhaskaran S, Kaur J, Singla A, Sharma T, Banerjee B D. Assessment of urinary cotinine levels in women with gynecological complaints at a tertiary care hospital: A pilot study. Indian J Public Health [serial online] 2017 [cited 2022 Jan 18];61, Suppl S1:63-5. Available from:

India is the second largest consumer of tobacco in the world.[1] Global Adult Tobacco Survey (2009–2010) revealed that about 35% of adults in India use some forms of tobacco. Use of smokeless tobacco (SLT) is estimated at 21%. On an average, 52% of adults are exposed to secondhand smoke (SHS) at home which is higher in rural compared to urban population (58% vs. 39%).[2] SLT is as addictive as smoked form and is considered more harmful to health since the nicotine absorbed is 3–4 times higher with longer retention time.[3]

A number of biochemical markers are available today to validate tobacco exposure. These include estimation of thiocyanate, nicotine, cotinine, and carboxyhemoglobin in the blood and carbon monoxide in the exhaled air.[4] Although thiocyanate, carbon monoxide, and carboxyhemoglobin are easy to estimate, these are not considered specific markers, since high levels might also be due to traffic emissions and diet.[5] Tobacco metabolite, nicotine has a very short half-life. Cotinine, which is the by-product by breakdown of nicotine, is excreted in both the saliva and urine. It has in vivo half-life of approximately 20 h and is typically detectable for several days (up to 1 week) after exposure to tobacco.[6] Urinary excretion of cotinine is hardly influenced by the flow of urine and pH. It is a widely accepted indicator of recent tobacco exposure including SHS.[7],[8] Hence, it is a good marker for estimating both active and passive exposure to tobacco.[9] Our study aims to assess the urinary cotinine levels in three common categories of gynecological complaints, namely, pelvic infections, infertility, and abnormal uterine bleeding (AUB) among nonpregnant women of reproductive age residing in East Delhi who sought treatment from gynecological outpatient clinic of Guru Teg Bahadur Hospital. The hospital caters to patients living in urban slums in Nand Nagri, Seema Puri, and Seelampur. The population density in these areas is very high, with congested living conditions. Majority belong to low-income group.

This was an exploratory study to assess the urinary cotinine levels in women with common gynecological conditions to provide a background for future well-planned studies to evaluate any association.

This cross-sectional pilot study was conducted in January 2015 at the outpatient clinic of the Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi.

A sample size of 192 was planned after taking into account the available finance. Approval was obtained from the Institutional Ethical Committee. A total of 192 consecutive women presenting at gynecological clinic were recruited for the study over 5 days. After obtaining written informed consent, each participant was interviewed for demographic details and tobacco use or exposure (any form) in self or family members based on a preset pretested questionnaire. The gynecological complaint necessitating hospital visit was also recorded. Spot urine sample was collected in a clean dry 100 ml plastic container for quantitative estimation of cotinine. The sample was maintained at room temperature. Urinary cotinine was measured by the ELISA technique (Calbiotech Cotinine ELISA Kit) within 4 h of sample collection at the Department of Biochemistry, University College of Medical Sciences, which is attached to the hospital. The study was conducted from part funds received from the World Health Organization for a project related to urinary cotinine estimation in pregnant women.[10]

Pelvic inflammatory disease (PID) was diagnosed based on syndromic approach, i.e., pain lower abdomen with one of the following – cervical motion, uterine, or adnexal tenderness. Infertility was defined as inability to conceive despite 1 year of unprotected intercourse. Menstrual flow outside of normal volume, duration, regularity, or frequency was considered AUB.

Statistical analysis was done using SPSS Version 20 (Armonk, NY: IBM Corp). Characteristics were compared between SHS and unexposed women by Chi-square or Fisher's exact test for categorical variables and by t-test for continuous variables. All levels of significance were set at P < 0.05.

All the 192 participants were included for final analysis. Broad categories of gynecological presentations included PID, infertility, and AUB. The mean age of women was 24.9 ± 4 years, with 44% being illiterate and 98% being homemakers.

None of the participants admitted to smoking or use of SLT. Fifteen percent (30/192) admitted to SHS.

Urinary cotinine levels in women not exposed to SHS (162/192) ranged widely from 8.09 to 63.44 ng/ml with a mean of 23.60 ± 12.00 ng/ml [Table 1]. Seventy-six percent (124/162) of these women had urinary cotinine values between 10 and 40 ng/ml while 14% (23/162) and 11% (18/162) had levels <10 ng/ml and >40 ng/ml, respectively. Mean urinary cotinine levels in women exposed to environmental tobacco smoke (SHS) was 23.82 ± 12.67 ng/ml, 80% (24/30) had urinary cotinine levels between 10 and 40 ng/ml, while 10% had levels >40 ng/ml.
Table 1: Secondhand smoke exposure from spouse in women

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This demonstrates that there was no significant difference in cotinine levels in the two groups, i.e., those exposed and not exposed to SHS.

PID (n = 139) was the most common gynecological complaint. Eighty-six percent (26/30) of SHS exposed women, and almost 90% (19/21) women with urinary cotinine >40 ng/ml had complaints of PID [Table 2]. Women with PID had significantly higher urinary cotinine level 24.9548 (±12.259) ng/ml as compared to women without PID: 20.2042 (±10.9248) ng/ml (P = 0.0144) (unpaired Student's t-test).
Table 2: Categorized urinary cotinine and gynecological presentations

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Comparison of urinary cotinine levels in the three categories of gynecological complaints showed that mean urinary cotinine levels in PID was 24.95 ± 12.26 ng/ml which was significantly higher than that in women with menstrual complaints (19.32 ± 10.29 ng/ml, P = 0.029). Mean urinary cotinine levels in infertile women were 22.42 ± 12.72 ng/ml.

Tobacco use (including the type) in spouse is given in [Table 1].

Secondhand exposure in overcrowded urban settlements, consumption of SLT products unknowingly may explain for the majority (76%) of the women having urinary cotinine levels ranging 10–40 ng/ml, since all the women had confirmed not using tobacco of any form. Locally manufactured tobacco containing toothpaste used due to misconceptions regarding its benefit in dental problems is also known in these localities (about 8.4% in our earlier study).[10]

The mean urinary cotinine values in pregnant women (nonusers) in our earlier study was 24.37 ± 20.14 ng/ml,[10] which is comparable to the levels observed in nonpregnant women in the current study (23.60 ± 12.00 ng/ml). Women with PID had significantly higher mean cotinine levels compared to those with infertility or menstrual complaints. Although association of reproductive outcomes and smoking has been well studied,[11] there is scant literature on the association of SLT or passive smoking and PID. Smoking has been identified as the strongest factor associated with PID in other studies.[12],[13] Possible mechanisms include the impairment of immune response to infection and altered tubal ciliary function, resulting in poor resistance to the ascending pathogenic organisms.[13]

Studies evaluating menstrual complaints and smoking suggest a close association between the two. Dysmenorrhea and amenorrhea were found to be higher among current smokers compared to those who had never smoked.[14],[15] Pan et al. studied the effect of passive smoking on menstrual abnormalities in 3466 unmarried women and concluded that passive smoking at home and at work was positively associated with menstrual dysfunction and dysmenorrhea (P < 0.01) and there was a dose–response relationship (P < 0.05).[16] No significant association was found between cotinine levels and menstrual complaints in the present study. Association between current cigarette smoking and increased risk for both primary and secondary infertility attributable to  Fallopian tube More Details dysfunction has been reported.[17] Comparable cotinine levels in infertility and PID groups in our study suggest possible association of latter as a cause of infertility.

Urinary cotinine values in the range of 10–40 ng/ml in majority of the women suggest possibility of SHS or use of a product containing SLT (locally made toothpaste, pan masala). Safe levels of cotinine have not been identified as yet. SHS puts these women unwittingly at risk of harmful systemic effects of tobacco. A well-designed study with a larger sample size is needed to confirm the association of elevated urinary cotinine values due to nonsmoked forms of tobacco exposure with PID and other problems of female reproductive morbidity. Ground work is required to understand the locally prevalent SLT products in use before undertaking such a study. It is also necessary to address other confounding factors such as nutrition, sexual practices, and habituation to other drugs while planning future projects. This was the limitation of our study.

Urinary cotinine level is a noninvasive and cost-effective method to assess tobacco exposure. The current study raises the possibility of an association of raised urinary cotinine due to exposure to SLT (SHS in the present study) and PID.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Available from: [Last accessed on 2016 Oct 02].  Back to cited text no. 1
Global Adult Survey 2009-2010. Ministry of Health & Family Welfare, Government of India.  Back to cited text no. 2
Rostron BL, Chang CM, van Bemmel DM, Xia Y, Blount BC. Nicotine and toxicant exposure among U.S. Smokeless tobacco users: Results from 1999 to 2012 National Health and Nutrition Examination Survey Data. Cancer Epidemiol Biomarkers Prev 2015;24:1829-37.  Back to cited text no. 3
Scherer G. Carboxyhemoglobin and thiocyanate as biomarkers of exposure to carbon monoxide and hydrogen cyanide in tobacco smoke. Exp Toxicol Pathol 2006;58:101-24.  Back to cited text no. 4
Hansen AM, Garde AH, Christensen JM, Eller N, Knudsen LE, Heinrich-Ramm R. Reference interval and subject variation in excretion of urinary metabolites of nicotine from non-smoking healthy subjects in Denmark. Clin Chim Acta 2001;304:125-32.  Back to cited text no. 5
Florescu A, Ferrence R, Einarson T, Selby P, Soldin O, Koren G. Methods for quantification of exposure to cigarette smoking and environmental tobacco smoke: Focus on developmental toxicology. Ther Drug Monit 2009;31:14-30.  Back to cited text no. 6
Moyer TP, Charlson JR, Enger RJ, Dale LC, Ebbert JO, Schroeder DR, et al. Simultaneous analysis of nicotine, nicotine metabolites, and tobacco alkaloids in serum or urine by tandem mass spectrometry, with clinically relevant metabolic profiles. Clin Chem 2002;48:1460-71.  Back to cited text no. 7
Jacob P 3rd, Yu L, Shulgin AT, Benowitz NL. Minor tobacco alkaloids as biomarkers for tobacco use: Comparison of users of cigarettes, smokeless tobacco, cigars, and pipes. Am J Public Health 1999;89:731-6.  Back to cited text no. 8
Curvall M, Elwin CE, Kazemi-Vala E, Warholm C, Enzell CR. The pharmacokinetics of cotinine in plasma and saliva from non-smoking healthy volunteers. Eur J Clin Pharmacol 1990;38:281-7.  Back to cited text no. 9
Radhika AG, Kaur J, Sharma T, Banerjee BD, Radhakrishnan G, Vaid NB. Pregnancy outcomes in smokeless tobacco users cohort study in a tertiary care Hospital. Open J Obstet Gynecol 2014;4:371-8.  Back to cited text no. 10
Li M, McDermott R. Smoking, poor nutrition, and sexually transmitted infections associated with pelvic inflammatory disease in remote North Queensland Indigenous communities, 1998-2005. BMC Womens Health 2015;15:31.  Back to cited text no. 12
Scholes D, Daling JR, Stergachis AS. Current cigarette smoking and risk of acute pelvic inflammatory disease. Am J Public Health 1992;82:1352-5.  Back to cited text no. 13
Jung AN, Park JH, Kim J, Kim SH, Jee BC, Cha BH, et al. Detrimental effects of higher body mass index and smoking habits on menstrual cycles in Korean women. J Womens Health (Larchmt) 2017;26:83-90.  Back to cited text no. 14
Windham GC, Elkin EP, Swan SH, Waller KO, Fenster L. Cigarette smoking and effects on menstrual function. Obstet Gynecol 1999;93:59-65.  Back to cited text no. 15
Pan X, Ding H, Han L, Wang L. Effects of passive smoking on menstrual function of perimarital women. Wei Sheng Yan Jiu 1999;28:23-5.  Back to cited text no. 16
Hull MG, North K, Taylor H, Farrow A, Ford WC. Delayed conception and active and passive smoking. The Avon Longitudinal Study of Pregnancy and Childhood Study Team. Fertil Steril 2000;74:725-33.  Back to cited text no. 17


  [Table 1], [Table 2]


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